Hospital to home transition services are designed to assist members transitioning from any health care facility to home. These services have been proven to significantly reduce hospital readmissions. The interventions are person-centered and can include:
- In hospital assessments
- SNF diversion
- Nursing home and/or rehabilitation facility visits (if required)
- Medication Reconciliation post-discharge
- Home visits
- Medication self-management education
- Chronic disease self-management coaching (e.g., identification of red flags)
- Developing a personal health record
- Physician appointment coaching and follow-up
- Telephonic follow-up